Healthcare Provider Details

I. General information

NPI: 1598952590
Provider Name (Legal Business Name): QUYNH L SEBASTIAN MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 15TH ST SUITE 709
SANTA MONICA CA
90404-1135
US

IV. Provider business mailing address

1260 15TH ST SUITE 709
SANTA MONICA CA
90404-1135
US

V. Phone/Fax

Practice location:
  • Phone: 310-917-4433
  • Fax: 310-917-4432
Mailing address:
  • Phone: 310-917-4433
  • Fax: 310-917-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA64443
License Number StateCA

VIII. Authorized Official

Name: DR. QUYNH L SEBASTIAN
Title or Position: CEO
Credential: M.D.
Phone: 310-917-4433